Naueen A. Chaudhry

A Fixed Stricture on Routine Cross-sectional Imaging Predicts Disease-Related Complications and Adverse Outcomes in Patients with Crohn's Disease

Background: Patients with Crohns disease (CD) typically undergo multiple cross-sectional imaging exams including computed tomography and magnetic resonance enterography during the course of their disease. The aim was to identify imaging findings that predict future disease-related poor outcomes. Methods: This was a retrospective, case control study at a single tertiary center. Cases were CD patients diagnosed with complications (bowel obstruction, perforation, internal fistula, or abscess); controls were CD patients without complications. Two radiologists blinded to clinical outcomes, independently scored cross-sectional imaging examinations obtained before the complication. Results: One hundred eight patients (67 F; 41 M) with CD (51 cases; 57 controls) were included. For the cases, 21 had internal fistulae, 15 had bowel obstructions, 13 had abdominal abscesses, and 2 developed bowel perforations. Patients with complications were more likely to have a fixed small bowel stricture on cross-sectional imaging (P = 0.01). A patient with a stricture and upstream dilatation was 3.4 times more likely to develop a complication in the next 2 years. When present in the setting of hypervascularity and/or evidence of active inflammation, the risk increased further to 15-fold. Cases were more likely to be active smokers (29% versus 12%, P = 0.033). Cases had more evidence of inflammation based on higher Harvey Bradshaw Index values and inflammatory biomarkers and lower hemoglobin values. Conclusions: Information from radiologic studies, especially the presence of fixed strictures, can predict future CD complications. These findings, along with smoking and ongoing inflammation, should alert the clinician to the possibility of future complications.

Pre-operative total parenteral nutrition improves post-operative outcomes in a subset of Crohn’s disease patients undergoing major abdominal surgery

Abstract Background Despite major advances in the medical management of Crohn’s disease (CD), a significant proportion of patients will require surgery within 5 years of diagnosis. Malnutrition is an independent risk factor for adverse post-operative outcomes following gastrointestinal surgery. Data on the value of pre-operative total parenteral nutrition (TPN) in CD patients are mixed and there is a paucity of data in the biologic era. We aimed to define the role of pre-operative TPN in this population. Methods This was a retrospective cohort study conducted at a tertiary referral center. CD patients who underwent major abdominal surgery were identified. Patients receiving pre-operative TPN were compared to controls. We compared the incidence of 30-day infectious and non-infectious post-operative complications between the two groups. Results A total of 144 CD patients who underwent major abdominal surgery between March 2007 and March 2017 were included. Fifty-five patients who received pre-operative TPN were compared to 89 controls. Twenty-one (14.6%) patients developed infectious complications (18.2% in TPN group vs 12.3% in non-TPN group, P = 0.34) and 23 (15.9%) developed non-infectious complications (14.5% in TPN group vs 16.9% in non-TPN group, P = 0.71). In a multivariate analysis, controlling for differences in baseline disease severity and malnutrition between groups, patients receiving pre-operative TPN for ≥60 days had significantly lower odds of developing non-infectious complications (odds ratio 0.07, 95% confidence interval: 0.01–0.80, P = 0.03). Weight loss of >10% in the past 6 months was a significant predictor of post-operative complications. Conclusions In a subset of malnourished CD patients, TPN is safe and allows comparable operative outcomes to controls. Pre-operative TPN for ≥60 days reduced post-operative non-infectious complications without associated increase in infectious complications.

Transmitted cardiovascular pulsations on high resolution esophageal impedance manometry, and their significance in dysphagia

AIM To investigate the behavior of pulsatile pressure zones (PPZ’s) as noted on high resolution esophageal impedance manometry (HREIM), and determine their association with dysphagia. METHODS Retrospective, single center case control design screening HREIM studies for cases (dysphagia) and controls (no dysphagia). Thoracic radiology studies were reviewed further in cases for (thoracic cardiovascular) thoracic cardiovascular (TCV) structures in esophageal proximity to compare with HREIM findings. Manometric data was collected for number, location, axial length, PPZ pressure and esophageal clearance function (impedance). RESULTS Among 317 screened patients, 56% cases and 64% controls had PPZ’s. Fifty cases had an available thoracic radiology comparison. The distribution of PPZ’s in these 50 cases and 59 controls was similar (average 1.4 PPZ/patient). Controls (mean 31.2 ± SD 12 years) were a significantly younger population than cases (mean 67.3 ± SD 14.9 years) with P < 0.0001. The upright posture PPZ pressure was higher in controls (15.7 ± 10.0 mmHg) than cases (10.8 ± 9.7 mmHg). Although statistically significant (P = 0.005), it was a weak predictor using logistic regression and ROC model (AUC = 0.65). Three dysphagia patients had partial compression from external TCV on radiology (1 aberrant subclavian artery, 2 dilated left atrium). The posture (supine vs upright) with more prominent PPZ’s impaired bolus clearance in 9 additional cases by > 20%. CONCLUSION Transmitted TCV pulsations observed in HREIM bear no significant impact on swallowing. However, in older adults with dysphagia, evidence of impaired bolus clearance on impedance should be evaluated for external TCV compression. These associations have never been explored previously in literature, and are novel.

Jackhammer oesophagus in a case of linitis plastica

A 52-year-old Caucasian woman presented with progressive nausea and vomiting, weight loss, and burning epigastric and chest pain. Initial oesophagogastroduodenoscopy (OGD) with biopsies demonstrated gastritis in absence of Helicobacter pylori. A gastric emptying study, CT scan with pancreatic protocol and a colonoscopy revealed no concerning findings. Calcium channel blockers and proton pump inhibitors offered little improvement. A high-resolution oesophageal impedance manometry was performed, which was significant for jackhammer oesophagus with maximum distal contractile index 11 052 mm Hg-s-cm. Another OGD was carried out for Botox injection to oesophagogastric junction. Repeat gastric biopsies reported gastric adenocarcinoma, further diagnosed as stage 4 linitis plastica with metastatic peritoneal carcinomatosis. To the best of our knowledge, this is the only case of linitis plastica associated with jackhammer oesophagus.

Tu1983 Correlation of Esophageal Diameter With Manometric Parameters in Subtypes of Achalasia Patients

Background: It was commonly thought that significantly dilated esophagus in Achalasia is associated with prolonged disease process. Comparing to type II Achalasia, type I diagnosed by manometry is thought to be a later stage achalasia which is less responsive to the treatment. Objective: To compare the esophageal diameter in different subtypes of achalasia based on High Resolution Impedance Manometry (HRIM) and therefore to further determine the clinical significance of this radiographic parameter. Method: Data of HRIM findings and esophagram of 71 Achalasia patients were retrospectively analyzed. Following parameters were obtained: height of the bolus column based on impedance recordings, lower esophageal sphincter residual pressure i.e. integrated relaxation pressure (IRP), and pan-esophageal pressure in supine and upright positions. The largest esophageal diameter was measured above esophagogastric (EG) junction on anteroposterior (AP) view of esophogram images. The patients were separated into 3 groups based on diameter of the esophagus as 8cm. The above manometric findings were compared with esophageal diameter. Esophageal diameter was also compared in different subtypes of Achalasia. Results: Thirty three out of 71 Achalasia patients with available esophogram were studied (M:F 15:18, age range 20-88 years; mean 58.6). Of these 33 patients, 6 patients were type I, 20 were type II, and 5 were type III Achalasia based on Chicago classification. Two patients were labeled as unclassified Achalasia due to presence of segmental peristalsis. Unexpectedly, Achalasia patients with wider esophageal diameter were more commonly seen in type II Achalasia rather than type I Achalasia as shown in table 1. 16 out of 20 type II Achalasia patients (80%) had dilated esophagus ≥ 5cm; comparing to 3 out of 6 type I patients (50%), and 1 out of 5 type III patients (20%) who had dilated esophagus of ≥ 5cm. There was no statistically significant correlation between esophageal diameter and LES residual pressure and pan esophageal pressures in both supine and upright swallows. However, the bolus height as determined by HRIM in upright position was associated with wider esophageal diameter on barium esophagram with correlation factor of 0.387 (P=0.07). Conclusion: In this study, we showed that wider esophageal diameter was associated with greater height of the bolus column in the upright position. Type II Achalasia patients are more commonly seen with larger esophageal diameter than other types. Since type II Achalasia responds to treatment better than other types, the degree of esophageal dilatation may not be a reliable prognosis predictor for Achalasia patients. Table 1. Correlation of esophageal diameter with subtypes of Achalasia